<html>

<head>
{php}html_header_show();{/php}

{literal}

 <style type="text/css" title="mystyles" media="all">

<!--

td {

	font-size:12pt;

	font-family:helvetica;

}

li{

	font-size:11pt;

	font-family:helvetica;

	margin-left: 15px;

}

a {

	font-size:11pt;

	font-family:helvetica;

}

.title {

	font-family: sans-serif;

	font-size: 12pt;

	font-weight: bold;

	text-decoration: none;

	color: #000000;

}



.form_text{

	font-family: sans-serif;

	font-size: 9pt;

	text-decoration: none;

	color: #000000;

}



-->

</style>

{/literal}

</head>

<body bgcolor="{$STYLE.BGCOLOR2}">

<p><span class="title">Prior Authorization Form</span></p>

<form name="prior_auth" method="post" action="{$FORM_ACTION}/interface/forms/prior_auth/save.php">

<table>

<tr>

	<td>Prior Authorization Number</td><td><input type="text" size="35" name="prior_auth_number" value="{$prior_auth->get_prior_auth_number()}"></td>

</tr>

<tr>

	<td><br><br>Comments</td>

</tr>

<tr>

	<td colspan="2"><textarea name="comments" value="{$prior_auth->get_comments()}" wrap="virtual" cols="75" rows="8">{$prior_auth->get_comments()}</textarea></td>

</tr>

{if $VIEW != true}

<tr>

	<td><br><br><input type="submit" name="Submit" value="Save Form">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<a href="{$DONT_SAVE_LINK}" class="link">[Don't Save]</a></td>

</tr>

{/if}

</table>

<input type="hidden" name="id" value="{$prior_auth->get_id()}" />

<input type="hidden" name="activity" value="{$prior_auth->get_activity()}">

<input type="hidden" name="pid" value="{$prior_auth->get_pid()}">

<input type="hidden" name="process" value="true">

</form>

</body>

</html>